Co-Occurring Disorders A primer

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Co-Occurring DisordersA primer

• Robert W. Johnson BS, AAP
• UAB Community Psychiatry Program REACT Team and
  Birmingham City Jail Diversion Project

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Defining Co-Occurring Disorders

• Co-Occurring disorder vs. Dual diagnosis
• Co-Occurring disorder is used because consumers
  often have more than two disorders.
• Co-Occurring disorder typically defined as
• a) At least one substance disorder plus
• b) At least one major mental disorder (i.e. Major
  Depression, Bi-polar mood disorder, any Psychotic
  disorder) (Axis I)

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Co-Occurring DisordersPopulation Estimates

• Approximately 10 million people in the U.S. have
  co-occurring substance and mental disorders
  (SAMHSA, 1997).
• 10 million Americans affected by two illnesses
• 3 million Americans affected by three illnesses
• 1 million Americans affected by four or more
  illnesses
• When consumers with other mental disorders are
  considered, (anxiety disorders, personality
  disorders) this number increases dramatically.

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Co-Occurring Disorders Prevalence

• National Co-Morbidity Survey
• 52 of those with alcohol disorders at some point
  in their lifetime also had a history of at least
  one mental disorder.
• 59 of those with other drug disorders at some
  point in their lifetime also had a history of at
  least one mental disorder.
• 84 of those that experienced a lifetime of
  co-occurrence report that their mental illness
  symptoms preceded their substance use disorder
  (Kessler et al, 1994).

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Co-Occurring Disorders Prevalence

• Prevalence of co-occurring disorders is higher in
  public service systems.
• Mental Health
• Substance Abuse
• Criminal Justice

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• Individuals with co-occurring disorders need to
  be thought of as the expectation not the
  exception.

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Co-Occurring DisordersRisk Factors

• Presence of substance use disorder quadruples the
  risk of having a co-occurring mental disorder.
• Presence of a mental disorder triples the risk of
  having a co-occurring substance disorder.
• Persons with any one substance use disorder have
  an increased risk for another substance disorder.

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Co-Occurring DisordersRelapse Factors

• The most common cause of mental illness relapse
  in COD consumers is substance abuse. Especially
  when the drug of choice is alcohol, marijuana, or
  cocaine.
• The most common cause of substance abuse relapse
  in COD consumers is untreated mental illness
  (SAMHSA, 1997).
• All mental disorders are consistently more
  strongly related to dependence than abuse
  (Kessler 1996).

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Co-Occurring Disorders A self defeating cycle
Substance Abuse

• Consumer
• With
• CODs

Mental Health
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Co-Occurring DisordersAddressing the Continuum

• Low Psych / Low Substance Abuse
• Low Psych / High Substance Abuse
• High Psych / Low Substance Abuse
• High Psych / High Substance Abuse

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Co-Occurring Disorders
High severity
III Less Severe MH More Severe SA
IV More Severe MH More Severe SA
Substance Abuse
I Less Severe MH Less Severe SA
II More Severe MH Less Severe SA
Low severity
Mental Health
High severity
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Co-Occurring DisordersForms of Care

• Sequential This model of service delivery for
  CODs is the traditional one. A person would
  receive treatment for their mental health
  disorder and then, sometime later, might receive
  a referral to another treatment provider to
  address their substance disorder or vice versa.

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Co-Occurring DisordersForms of Care continued

• This model is unsuccessful, especially if the
  person has serious and active symptoms in one or
  both categories of disorder.
• The continuity of care is broken. There is no
  mechanism in place to address impairments
  associated with co-morbidity (i.e. Social
  isolation, impaired vocational capability, poor
  relationships, ADLs, quality of life, etc.)

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Co-Occurring DisordersForms of Care continued

• Parallel In a parallel model of intervention,
  the person receives treatment for their mental
  health disorder from one provider or treatment
  setting and receives treatment for their
  substance use disorder from another provider
  simultaneously.

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Co-Occurring DisordersForms of Care continued

• Burden is placed on the individual to negotiate
  the two treatment systems and sometimes
  reconcile, inconsistent treatment
  recommendations.
• In many cases, people are often engaged in
  treatment programs simultaneously, with no
  communication between service providers.
• Historically, this intervention may have
  consisted of someone seeing a psychiatrist for
  their mental health while being referred to AA to
  address their substance abuse.

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Co-Occurring DisordersForms of Care continued

• Parallel treatment is difficult for all but the
  highest functioning subgroup of people with CODs
  successful achievement stemming from long term
  symptom stabilization in one category of their
  disorders and then addressing the other.
• Being challenged by integrated model of
  intervention nationwide.

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Co-Occurring DisordersForms of Care continued

• Integrated In this model, treatment of all of
  the persons disorders are considered
  simultaneously, in the same service setting,
  developed by and delivered by cross trained staff
  (MH and SA).
• Service providers are completely engaged in the
  treatment planning for both categories of
  disorder. Service is typically delivered by a
  multidisciplinary treatment team which includes
  mental health and substance abuse professionals.

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Co-Occurring DisordersForms of Care continued

• Difficult to find professionals who have
  experience in both mental health and substance
  abuse. There is a lack of knowledge stemming
  from both mental health and substance abuse in
  regard to the other discipline.
• Requires a paradigm shift from both disciplines.
  Treatment providers are finding it difficult to
  adapt to new modalities of treatment (i.e. Harm
  reduction).

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Co-Occurring DisordersForms of Care continued

• Historically, treatment provision in substance
  abuse, has been 12 step or abstinence based.
  NAMI shows that abstinence based modalities have
  been ineffective in treating consumers with CODs.
• Battle for service provision.
• Whose clients are they?
• Who is willing to provide services?

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Co-Occurring DisordersBridging the Gap

• Community Action Grant UAB-CPP Birmingham
• Task Force Alabama Commissioner of Mental
  Health Mental Retardation
• Development of SCATTC (2002) Southern Coast
  Addiction Technology Transfer Center. Serves
  Alabama and Florida. Part of the National ATTC
  Network with a Unified Mission of
• Increase knowledge skills of addiction
  treatment practitioners.
• Heighten the awareness, knowledge, and skills of
  all professionals who interface with addiction
  treatment.
• Foster regional and national alliances among
  practitioners, researchers, policy makers,
  funders and consumers.

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Co-Occurring DisordersBridging the Gap

• PACT ACT Teams Substance Abuse Specialist
  position, financially supported by Alabama Dept.
  of Mental Health Retardation (Addictions).
• The Alabama Council of Community Mental Health
  Boards.
• ASADS Conferences Co-Occurring Tracts
• Criminal Justice and Mental Health Conferences
• Integrated Treatment Substance Study Group
• Train the Trainers Cross training through
  SCATTC

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• Individuals with co-occurring disorders need to
  be thought of as the expectation not the
  exception.

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Co-Occurring DisordersFurther Readings
Resources

• Integrated Treatment for Dual Disorders A guide
  to effective practice. Mueser, Noordsy, Drake,
  and Fox.
• Criminal Justice / Mental Health Consensus
  Project. www.consensusproject.org
• Motivational Interviewing, 2nd Edition Preparing
  People for Change. Miller, Rollnick, and
  Conforti
• U.S. Dept of Health and Human Services Substance
  Abuse Mental Health Services Administration
  (SAMHSA) www.samhsa.gov
• The National Gains Center (COD and Justice
  System) www.gainsctr.com
• National Alliance for the Mentally Ill (NAMI)
  www.nami.org
• National Addiction Technology Transfer Center
  Network (ATTC) www.addictioned.org
• Co-Occurring Disorders A Training Series for
  Counselors www.fmhi.usf.edu/cmh/training/ole/ole.
  html
• Southern Coast Addiction Technology Transfer
  Center (SCATTC)
• Joan Leary - SCATTC Project Manager for Alabama